Traditional approaches to addiction recovery have championed abstinence as the “right” path. Maintenance treatment for heroin or opiate painkillers has been used very cautiously—typically to rapidly taper addicts off opiods rather than for long-term use. As a result, when Hazelden announced last month that it will begin using medication-assisted treatment indefinitely for appropriate patients, many traditionalists responded with incredulity.

Opiod maintenance in the US primarily relies on two drug options: methadone, which has been around since the 1960s, and buprenorphine, which came on the market 10 years ago. Both drugs work by triggering opiate receptors in the brain, easing withdrawal and reducing the euphoric effects of heroin. Buprenorphine (brand name Suboxone) also includes naloxone, the anti-overdose drug that is added to prevent abuse.

Experts generally agree that methadone is more effective than Suboxone, but not by much. Studies have found that the recommended dose of Suboxone is better than low-dose methadone, but no better than high-dose. Yet methadone poses a greater risk of overdose and is easier to abuse. All things being equal, therefore, bupe is the preferred treatment. But all things are not equal, and most unequal is a patient's ability to pay.

The cost of bupe maintenance varies: many private insurance plans cover the drug, together with prescribing doctor’s visit; for people who pay out of pocket, the cost ranges roughly between $250 and $500 a month, not including doctor’s visit. Long a cheap generic, methadone is much less expensive. It is also more likely than Suboxone to be covered by public health insurance—though this varies by state—and some nonprofit and government-funded methadone clinics use a sliding scale to set patient co-pays.

“Suboxone is a white-collar alternative to methadone and NA," Tom says.

The cheaper generic version of Suboxone expected in 2013 may be postponed. Manufacturer Reckitt began hiking prices on Suboxone tablets earlier this year, likely in an effort to migrate Suboxone maintenance patients to the costlier sublingual film version for which they hold a patent through 2022. Now, Reckitt has announced its intention to withdraw the tablet form over the next six months, citing an increased risk of accidental pediatric exposure and poisoning. (Oddly, Reckitt did not move to immediately pull the tablets.) As a result, cheaper generic buprenorphine that would likely expand access is set to be delayed for "safety concerns."

Compare the situations of Tom and Jenna, who in many ways exemplify our nation's two classes of opiate maintenance patients.

Tom, who lives in Atlanta and is 25, began using opiods as a freshman in college. Throughout high school he had experimented with “alternative” drugs like psilocybin mushrooms and LSD, and steeping an opiod tea seemed like the next step in his drug evolution. But when eBay began prohibiting the sale of the dried poppies he had been purchasing, Tom went into withdrawal for the first time. He moved from snorting heroin to shooting it, eventually dropping out of college to become, as he put it, a “full-time junkie."

By the time Tom decided to get a handle on his habit and return to school, he had defaulted on his college loans. His school has a hardship clause; if he could demonstrate that chemical dependency was at the root of his default—and agree to maintenance therapy—he would could go back to college and be granted partial forgiveness on his loan interest. His private psychiatrist wrote him a prescription for a 30-day supply of Suboxone. He’s been on the drug for the past two years and is set to graduate this spring.

Tom’s Suboxone regime is expensive—$500 a month with doctor's visit—but health insurance through his parents’ policy covers the entire cost. And he is happy with the treatment. It has allowed him to be more functional with no “druggy side effects.” He has gone off Suboxone occasionally to binge on other opiods, but infrequently, he says. For now, he has no plans to stop buprenorphine, and his parents are willing to foot the bill for health insurance after he ages out of their policy.

Tom has not gone to 12-step meetings or other addiction-related therapy during his maintenance treatment—such attendance is rarely a requirement for bupe. By contrast, most methadone maintenance programs are highly regulated and often require meetings for eligibility. Tom never considered taking methadone for maintenance, saying that he wanted to avoid daily clinic visits and registering with the government for a program for people who are chemically dependent. “Suboxone is a kind of white-collar alternative to methadone and NA," he says. "If you come from a family with money and have health insurance, you can take it and you don’t have to do any program.”

Jenna, a 34-year-old mother in Denver, has taken methadone almost continuously for 15 years. She is on Medicaid—public health coverage for low-income Americans—and her local methadone clinic has a special program for mothers. Her weekly co-pay for methadone is $27. She also attends 12-step meetings where her fellow members are generally accepting of her methadone maintenance. Jenna says that she and most of her friends on methadone would prefer to take Suboxone, but they can’t afford it: Colorado’s Medicaid program does not cover bupe, and private health insurance is too expensive.

The growing number of private doctors prescribing Suboxone is causing a quiet treatment revolution.

An ongoing study of buprenorphine maintenance in New York CIty has found that it is typically available based not on a patient's need but on their pocketbook, and poor people need not apply, according to Laura G. Duncan, the study's research coordinator. As for those on Medicaid, coverage of bupe, when available, usually requires jumping through a series of bureaucratic hoops. Patients sometimes need a referral from a primary care physician or specialist, which further jacks up the price.

Methadone maintenance is generally provided through Opiod Treatment Programs (OTPs), some of which also offer other services such as inpatient detox and counseling. A 2008 SAMHSA study found that 72% of OTPs without additional services used only methadone—no buprenorphine. In 2010 some 304,500 opiate users in the US got medication-based treatment from an OPS; of these only 2% were on bupe. A total of 27,500 opiate users received buprenorphine; of these 76% were prescribed the drug outside of OTPs—through private insurance.

The growing number of private doctors prescribing Suboxone is causing a quiet revolution in addiction treatment. In order to write a scrip for bupe, which is a Schedule III narcotic, doctors have to receive a waiver, which involves completing at least eight hours of training. A recent SAMHSA survey found that 53% of waivered physicians had no prior experience using methadone for maintenance; 56% were in nonaddiction specialties.

The vast majority of doctors who prescribe bupe have affluent caseloads. Those who serve poor and uninsured patients tend not to get the waiver, presumably on the assumption that their patients cannot afford the treatment, according to Duncan. “Bupe is still unusual in low-income medical settings due to economic inaccessibility, so providers there may not be as knowledgeable about it." Even those doctors who are aware of Suboxone tend not to waste time educating patients about unavailable treatments. This cycle reinforces itself.

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